Role of veno-venous extracorporeal carbon dioxide removal in coronavirus disease 2019 associated acute respiratory distress syndrome

Introduction: Standard management for acute respiratory distress syndrome secondary to Coronavirus disease 2019 (COVID-19) includes low tidal volume lung-protective mechanical ventilation, paralytics and prone positioning Permissive hypercapnia is allowed to reduce the risk of barotrauma Despite stabilization of oxygenation, some patients develop progressive respiratory acidosis This may be due to a combination of mucus plugging and microthrombi in the lungs Methods: We describe the use of veno-venous extracorporeal carbon dioxide removal (ECCO2R) in three patients with COVID-19 associated severe ARDS and refractory Results: Patient 1 showed improvement in respiratory acidosis following initiation of ECCO2R, however after 24 hours of stabilization he developed progressive hypoxemia and cardiac arrest without return of spontaneous circulation Patient 2 showed improvement in respiratory acidosis following initiation of ECCO2R and remained stable for several days before developing progressive hypoxemia requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO) support He was successfully weaned off V-V ECMO after two weeks Patient 3 also remained stable on ECCO2R support for a week before developing refractory hypoxemia and cardiac arrest without return of spontaneous circulation Conclusion: In severe COVID-19 ARDS on optimal lung-protective ventilation, progressive hypoxemia may lag behind hypercapnia, rendering carbon dioxide removal alone insufficient We suggest that patients who develop progressive respiratory acidosis despite maximum optimization of lung-protective ventilation should be considered for V-V ECMO support rather than ECCO2R alone